Basic Information
| Provider Information | |||||||||
| NPI: | 1023500113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORDENAVE | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | PSYD, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW STE 110 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 E 78TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554201402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528545034 | ||||||||
| FaxNumber: | 9528545363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2018 | ||||||||
| LastUpdateDate: | 11/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 3557-57 | WI | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | 6325 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.